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CASE REPORT (10.

00)
A baby boy 1 day old, came to emergency installation referred from
RSI Kudus with chief complain that he doesn’t have anus

Chief complain : doesn’t have anus

History of Illness :
The baby was born from G3P2A0 38 weeks from 35 years old
mother, aterm, by midwife at RSI Kudus with body weight 2100
grams. Ante natal care was done regular to midwife. After the
baby was born, the midwife found that, the baby doesn’t have
anus. There was meconeum came out from the penis. IV line to
umbilical line was performed and OGT was inserted. Because
there was no pediatric surgeon, the patient was sent to RSDK.
PHYSICAL EXAMINATION :
General condition : Cry loud, Active movement
Vital Sign :
RR : 46 times/mnt (reguler, adequate deep breath)
HR : 108 times/mnt (reguler, enough tone and volume)
T : 370C (A)
BW : 2100 gram

Head & Neck :


Conjunctiva palpebra was not pale, Mongoloid face (-), low seat ear
(- ), saddle nose (-), labioschizis (-), palatoschizis (-)

Chest:
Heart
I : Ictus cordis was not seen
P : Ictus cordis palpated on SIC V, 1 cm medial LMCS
P : Configuration within normal limit
A : Basic sound clear, no additional sound
Lung
I : Static : right hemithorax = left hemithorax
Dynamic : right hemithorax = left hemithorax
Pa : Tactile fremitus symetric in both hemithorax
P : Sonor all around area
A : Vesikular sound (+), additional sound (-)

Abdomen :
I : Distended (-), bowel pattern and movement (-),
Pa : Soepel (+), no tenderness, no muscle rigidity
P : Tympanic
A : Bowel sound (+)
Extremities Superior Inferior
Cyanotic -/- -/-
Cold Acral -/- -/-
Motoric 5/5 normal 5/5 normal
Simean crease -/- -/-
Syndactyly -/- -/-
Polydactyly -/- -/-

External Genital : Male, meconium (+)


Working diagnosis: (10.15)
Anorectal Malformation with suspected recto urethra fistules DD recto vesica fistules
adequate

Initial Management :
IpDx :
S:-
O : Baby gram, invertogram
IpTx :
- Oxygen 3 liter / minutes nasal canule
- Keep warmth
– IVFD D5% ¼ NS 16 dpm micro
– Maintain OGT
– Applied DC  came out yellowish clear urine
– Pro colostomy
IpMx :
– Complaint, general condition, vital sign, routine blood examination, Ureum/Creatinin,
electrolyte and coagulation time test
IpEx :
– Informed consent, diagnosis, management and prognosis
Radiology (11.20)
Baby gram
Invertogram

Laboratory study (12.20)


Hb : 15,4gr/dl (13,0-16,0)
Leuko : 18.0 mm3 (4000 – 10000 )
Tr : 210.000/mm3 (150.000-400.000)
Ht : 46.4 % (40% - 54%)
GDS : 125 mg/dL (80-140)
Ur : 24 mg/dl (15-39)
Cr : 0,6 mg/dl (0,5-1,5)
Na : 137 mmol/L (136-145)
K : 4,1 mmol/L (3,5-5,1)
Cl : 105 mmol/L (98-107)
Diagnosis (12.25)
Anorectal malformation with recto urethra fistule adequate

Management :
pDx :
S:-
O:-
pTx :
- Oxygen 3 liter / minute nasal canule
- Keep warmth
– IVFD D5% ¼ NS 16 dpm micro
– Pro colostomy

pMx :
– Complaint, general condition, vital sign

IpEx :
– Informed consent, diagnosis, management and prognosis
Operation report (13.00 - 14.30)
• Patient lied down under general anesthesia
• Antiseptic and Aseptic operation area
• Transverse incision on contra McBurney about 3 cm, deepend until
oblique external fascia, splitting OAE, OAI, tranversus muscle until
peritoneum.
• Open the peritoneum, came out clear yellowish fluid, explored and
identified sigmoid colon then bring it out from peritoneal cavity
• Bridging colon 5 times
• Sutured sigmoid colon seromuscular on fascia with 8 anchored suture
with PGA 3-0 on 8 sites (proximal at lateral side)
• Plicated the colon, suture the edge of plication to the skin and serosa with
silk 3.0 interrupted at 8 sites
• Incised the colon inline the length
• Evaluated passage of distal and proximal punctum (came out faeces from
proximal punctum), wash out the distal punctum from the stomach and
from the fistule
• Place the colostomy bag
• Operation finished
Post op Diagnosis
Anorectal malformation with recto urethra fistule adequate
Post colostomy
Management :
pDx :
S:-
O:-
pTx :
- Oxygen 3 liter / minute nasal canule
- Keep warmth
– IVFD D5% ¼ NS 16 dpm micro
– Maintain OGT
– Maintain DC
– Paracetamol 60 mg/ 8 hrs per oral
– Stoma care
pMx :
– Complaint, general condition, vital sign, routine blood examination,
Ureum/Creatinin, electrolyte, coagulation time test
pEx :
– Diagnosis, post operation management, stoma care, prognosis
Follow Up D+1
S : nausea (-), headache (-)
O : condition : good
Abdomen:
I : Distended (-), bowel pattern and movement (-),
Stoma: reddish (vital), faeces (+)
Pa : Soepel (+), no tenderness, no muscle rigidity
P : Tympanic
A : Bowel sound (+)
A : stable
P :
– IVFD D5% ¼ NS 16 dpm micro
– Aff OGT
– Aff DC
– Paracetamol 60 mg/ 8 hrs per oral
– Stoma care
– Breastfeeding ad libitum